Postthrombotic syndrome with ulcer of left lower extremity

This code signifies a chronic complication of deep vein thrombosis (DVT) affecting the left lower extremity, characterized by persistent venous hypertension leading to skin breakdown and ulcer formation. The ulcer is a direct sequela of the postthrombotic changes, such as venous reflux and obstruction.

Apply this code when documentation explicitly states postthrombotic syndrome with an active ulcer on the patient's left lower limb. This diagnosis is supported by a history of DVT in the affected extremity and clinical findings consistent with chronic venous insufficiency and ulceration.

• Ensure the laterality (left lower extremity) is clearly documented.
• Do not use this code for venous stasis ulcers without a documented history or diagnosis of postthrombotic syndrome.
• Code any associated infections of the ulcer separately.